An Assessment of Open Fracture Management in

Hospitals in Malawi Before and Immediately After

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Implementing Open Fracture Guidelines

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Maureen Sabawo, BSc, Zahra Jaffry, BSc(Hons), MBBS, MRCS, PGCert, Linda Chokotho, PhD, MPH, MBBS*, and
Alexander Thomas Schade, MPH, FCS(ECSA), MBBS*

Investigation performed at Zomba Central Hospital, Zomba, Malawi; Mangochi District Hospital, Mangochi, Malawi; Salima District Hospital,
Salima, Malawi; and Mulanje District Hospital, Mulanje, Malawi

Background: Open fractures, a common consequence of road traffic collisions, are associated with a high risk of
complications. The introduction of standard guidelines has been shown to improve patient care and reduce the risk of
complications in several countries. In September 2021, the Malawi Orthopaedic Association/Arbeitsgemeinschaft für
Osteosynthesefragen Alliance (MOA/AOA) guidelines and standards for open fracture management were introduced in
Malawi. This study aimed to assess the management of open fractures in hospitals in Malawi, before and after
implementing a training course on the MOA/AOA open fracture guidelines.
Methods: This was a descriptive and quantitative, before-and-after study that reviewed the medical files of patients with
open fractures at Zomba Central Hospital and Mulanje, Salima, and Mangochi district hospitals over two 3-month periods.
Variables included initial assessment; antibiotic prophylaxis; place of debridement; type of anesthesia; treatment of the
open fracture in the emergency department, operating room, and wards; and short-term complications requiring hospital
treatment.
Results: A total of 88 open-fracture case files were reviewed; 43 were prior and 45 were subsequent to the im-
plementation of the open fracture guidelines. The overall median patient age was 36 years (interquartile range, 27 to 45
years), and 91% (80) were male. Limb neurovascular status assessment and documentation improved from 26% (11) of
the patients before the guidelines to 62% (28) afterward (p = 0.0002). The percentage who underwent debridement in the
operating room significantly increased from 19% (8) to 69% (31) (p = 0.01). The percentage who underwent debridement
under general or spinal anesthesia significantly increased from 5% (2) to 38% (17) and from 12% (5) to 29% (13),
respectively (p= 0.001). The wound infection rate decreased from 21% to 11%, but this was not significant, and there was
no change in the overall complication rate (p = 0.152).
Conclusions: This study suggests that training on the MOA/AOA open fracture management guidelines followed by their
implementation can lead to at least temporary improvement in the management of open fractures. Nevertheless, addi-
tional studies need to be performed to understand the effect on long-term patient outcomes.
Levels of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

I
njuries play a substantial role in the global disease burden, annually1. Notably, these deaths surpass the combined mor-
accounting for approximately 19.8% of disability-adjusted tality figures for HIV/AIDS (human immunodeficiency virus/
life years (DALYs) lost and causing 4.8 million deaths acquired immunodeficiency syndrome), tuberculosis, and

*Linda Chokotho, PhD, MPH, MBBS, and Alexander Thomas Schade, MPH, FCS(ESCA), MBBS, contributed equally to this work.

Disclosure: This research was funded by the AO Alliance, AO Trauma. The Article Processing Charge for open access publication was funded by the
Wellcome Trust (grant no. 203919). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://
links.lww.com/JBJSOA/A613).

Copyright Ó 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved. This is an open access article
distributed under the Creative Commons Attribution License 4.0 (CC-BY), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
JBJS Open Access d 2024:e23.00078. http://dx.doi.org/10.2106/JBJS.OA.23.00078 openaccess.jbjs.org 1
 An Assessment of Open Fracture Management in Malawi Before and After Open Fracture Guidelines
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malaria, and injuries are the leading cause of death among (within 1 hour after hospital presentation), thorough surgical
males aged 15 to 29 years2-5. Low and middle-income countries wound debridement in the operating room under general or spinal
(LMICs) bear the brunt of this burden, having 90% of all anesthesia, proper bone stabilization, and early soft-tissue wound
deaths due to road traffic collisions (RTCs)3. coverage to optimize outcomes25.
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In Malawi, the average DALY loss due to RTCs was 180,000 However, there is insufficient evidence from hospitals in
per year between 2010 and 20206,7. A substantial portion of Malawi to evaluate the management of open fractures and
fractures in Malawi, estimated at 66.5%, result from RTCs, while assess whether it is in line with these newly developed MOA/
falls account for 16%6. The injured parties in RTCs are mainly AOA guidelines. Thus, the aim of the present study was to
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pedestrians (32%), cyclists (28%), and motorcyclists (17.8%)6,8. assess the management of open fractures in hospitals in Malawi
Open fractures, which are a common consequence of RTCs before the training course on the MOA/AOA guidelines com-
and falls, have an incidence of 30 per 100,000 person-years in pared with immediately afterward.
high-income countries3,4. These fractures are orthopaedic emer-
gencies that need to be prioritized because they are associated with Materials and Methods
an 18% risk of infection and 15% risk of amputation in LMICs9. Study Design and Participants
In most LMICs, only 20% of patients with open fractures return
to work within 1 year after the injury, resulting in far-reaching
consequences for national economies, costing LMICs as much as
T his was a descriptive and quantitative, before-and-after
study reviewed the medical files of patients with long-bone,
hindfoot, and midfoot open fractures (involving the humerus,
3% of their annual gross domestic product3,9. However, evidence radius, ulna, femur, tibia, fibula, calcaneus, talus, tarsals, and
suggests that high-quality open-fracture management is associ- metatarsals) treated from July 2021 to mid-February 2022. All
ated with improved outcomes and quality of life10-13. Therefore, patients who presented or were admitted to the 4 participating
many evidence-based guidelines have been formulated to improve hospitals from July 2021 to mid-February 2022 and had radio-
the complex management of open fractures11,14-17. graphic confirmation of an open fracture of a long bone or of the
Malawi is geographically divided into 4 regions: southern, hindfoot or midfoot were eligible for inclusion in the study.
northern, central, and eastern. The treatment of fractures in Patients with an open fracture of the hand or forefoot were
Malawi is provided through a 2-tiered health-care system. The excluded from the study25. The participating hospitals were
secondary level of care is delivered by 117 orthopaedic clinical Zomba Central Hospital and Salima, Mangochi, and Mulanje
officers (OCOs) at 28 district hospitals distributed across the district hospitals.
country. OCOs are non-physicians with a diploma in clinical The study protocol was approved by the College of Medi-
orthopaedics or a bachelor’s degree in trauma and orthopaedics cine Research Ethics Committee (P.08/21/3369) and by each
who provide nonoperative care for orthopaedic conditions as well participating hospital’s research management committee. Because
as emergency orthopaedic surgery for select cases such as open we collected anonymous secondary data, individual consent was
fractures, dislocations, and acute infections18. Subsequently, more not required.
specialized care is offered at the country’s 4 tertiary hospitals by 9 All data collection commenced at the same time, on
specialized trauma and orthopaedic surgeons. Each tertiary hos- November 15, 2021. Case files from July to September 2021
pital is situated in 1 of the 4 major cities within the respective were reviewed retrospectively, and those from November 15,
regions mentioned earlier18-20. 2021, to February 15, 2022, after the training course that was
Orthopaedic surgeons are specialist doctors with 4 years held in September 2021, were reviewed prospectively.
of postgraduate training, and they provide operative care for all
orthopaedic and trauma conditions18. Plastic surgeons play a Data Collection
crucial role in providing reconstructive surgery to patients with A data capture form was used to gather information from patient
traumatic injuries18,20. However, staffing of plastic surgeons at medical files and register books (see Appendix 1). This infor-
the trauma units at both levels remains minimal19. Only 2 mation included demographics as well as details regarding the
plastic surgeons are currently available; both are situated in initial assessment (including a primary survey and neurovascular
burn units within tertiary hospitals, and neither is situated at status); antibiotic prophylaxis; temporary fracture immobiliza-
the recruitment hospitals of this study21. tion; where the debridement was performed; type of anesthesia;
As in many LMICs, the burden of injuries in Malawi is soft-tissue wound closure and definitive treatment of the fracture
rising at a time when its health-care system has inadequate in the emergency department, operating room, and wards; short-
infrastructure and equipment and a shortage of personnel to term complications requiring hospital treatment; and date and
treat injuries, especially open fractures, in both pre-hospital time of referral, treatment before referral, and reason for referral.
and in-hospital settings19,22-24. Data clerks recorded the demographics, disposition, and
In September 2021, locally adapted Malawi Orthopaedic discharge and/or referral details, and OCOs recorded the clinical
Association/Arbeitsgemeinschaft für Osteosynthesefragen Alliance information in the initial management and definitive manage-
(MOA/AOA) guidelines were implemented through a training ment sections. The principal investigator (PI) completed the
course. These guidelines recommend a primary Advanced Trauma complication section and verified each item of information
Life Support (ATLS) survey, assessment and documentation of captured by the data clerks and OCOs against the radiographs
neurovascular status, early administration of antibiotic prophylaxis and wound photographs, to determine whether the patient
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treatment was consistence or inconsistent with the guidelines26. nonparametric data). Patient data collected before and after the
The PI also assessed wound infection using the ASEPSIS scoring course were compared using a Kruskal-Wallis test (for non-
system25,27. At the end of each month, the PI entered the com- parametric numerical data) or chi-square test (for categorical
pleted and verified data into an electronic database. data). A p value of <0.05 was considered significant, and 95%
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confidence intervals (CIs) were calculated.

Definitions and Outcome Ascertainment
The collected data consisted of the mechanism of injury (RTC, fall Results
total of 88 open-fracture case files were identified across the
from a standing height or above, sports, other), initial assessment
A
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and treatment in the emergency department (primary survey 4 participating hospitals; 43 of the 88 injuries occurred
using ATLS protocol, neurovascular assessment, antibiotics, before the guideline training course and were analyzed retro-
temporary immobilization), management in the operating room spectively, and 45 occurred after the course and were analyzed
(place of debridement, type of anesthesia), definitive treatment prospectively. Zomba Central Hospital treated 34% (30); Man-
(plaster of Paris [POP], external fixation, internal fixation, straight gochi District Hospital, 24% (21); Mulanje District Hospital,
arm traction, skeletal traction, and amputation), management in 16% (14); and Salima District Hospital, 26% (23). The median
the ward (timing of antibiotic administration, duration of anti- age of the patients was 36 years (IQR, 27 to 45 years), and 91%
biotics, tetanus toxoid vaccination status, wound care), and out- (80) were male. There was no significant difference between the
comes (including short-term complications requiring hospital patient groups before and after the guideline training course
treatment, such as wound infection, compartment syndrome, and with respect to age (p = 0.083), gender (p = 0.761), occupation
amputation)27 (see Appendix 1). (p = 0.632), comorbidity (p = 1.000), other associated injuries (p
= 0.295), or median days from the injury to presentation at the
Statistical Analysis hospital (p = 0.116) (Table I).
Data were analyzed quantitatively using RStudio (R Foundation The most common cause of the open fractures was an
for Statistical Computing)28. Categorical demographic variables RTC, at 60% (53), and half of the patients in this group (49%
are presented as percentages and frequencies. Continuous vari- [26]) had been riding a motorcycle at the time of the accident
ables are presented as the mean and standard deviation (for (Table II). The tibia was the most commonly fractured bone, at
parametric data) or median and interquartile range (IQR) (for 67% (59).

TABLE I Baseline Demographics of Participants with an Open Fracture Before and After the Guidelines*

Before (N = 43) After (N = 45) Overall (N = 88) P Value

Age (yr) 31 (25-42) 40 (28-54) 36 (27-45) 0.083

Male 93% (40) 89% (40) 91% (80) 0.761
Other associated injuries† 5% (2) 13% (6) 9% (8) 0.295
Occupational status‡ 0.632
Business 25% (2) 27% (6) 27% (8)
Student 25% (2) 23% (5) 23% (7)
Farmer 12% (1) 14% (3) 13% (4)
Office work 25% (2) 5% (1) 10% (3)
Unemployed 0% (0) 14% (3) 10% (3)
Self-employed 0% (0) 9% (2) 7% (2)
Minor 0% (0) 5% (1) 3% (1)
Other 12% (1) 5% (1) 7% (2)
Referred from§ 0.07
Self-referral 68% (25) 56% (24) 61% (49)
Health center 11% (4) 21% (9) 16% (13)
District hospital 16% (6) 12% (5) 14% (11)
Private clinic 0% (0) 12% (5) 6% (5)
Christian Health Association of Malawi hospitals 5% (2) 0% (0) 2% (2)
Days from injury to hospital presentation 0 (0-1) 0 (0-0) 0 (0-1) 0.116

*Values are given as the percentage of patients with the number in parentheses, except for age and days from injury to hospital, which are given
as the median with the IQR in parentheses. †Other associated injuries were defined as head injury, abdominal injury, chest injury, spinal injury, and
closed long-bone fractures. ‡66% (58) of the patients had missing data. §9% (8) of the patients had missing data.
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remained the same, 1 day (IQR, 0 to 1 days) before and 1 day

TABLE II Mechanisms of Injury*
(IQR, 0 to 3 days) after the guideline training course. There
No. (%) of Patients was no significant improvement (p = 0.083) in the percentage
who underwent open-fracture debridement before referral,
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RTC 60% (53) 40% (4) before and 64% (7) after the guideline implementation
Motorcyclist 49% (26) (Table IV).
Pedestrian 26% (14)
Car driver 23% (12) Complications
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Bicyclist 2% (1) A total of 24 patients (27%) developed complications. The rate

Blunt trauma 11% (9) of wound infections was 21% (9) before the guideline training
course and 11% (5) after. The rate of amputation was 5% (2)
Fall from greater than a standing height 10% (8)
before and 7% (3) after. Both of the patients who underwent
Crocodile bite 7% (6) amputation in the before-guideline group had developed an
Assault 5% (4) uncontrollable infection; 2 of the 3 amputees in the after-
Fall from a standing height 2% (2) guideline group had an avascular limb in the absence of vascular
Sport 2% (2) reconstruction and the third had a mangled extremity with
the absence of reconstruction capabilities. No patient died before
*5% (4) of the patients had missing data. Values are given as the the implementation of the guidelines, whereas 7% (3) died after
percentage of the remaining 84 patients with the number in implementation due to tetanus, an unknown cause, and septi-
parentheses, except for the breakdown of the individuals injured in cemia (2% [1] each). However, there was no significant differ-
RTCs, which are of the 53 with RTC injuries.
ence (p = 0.152) in the overall rate of complications between
before and after the guideline training course (Table IV).

Initial Assessment and Management of Open Fractures in the Discussion

Emergency Department
The rate of ATLS assessment and documentation significantly
improved (p = 0.029) from 60% (26) to 82% (37). There was
T his study showed an improvement in the management of
open fractures after implementation of the MOA/AOA
guidelines through a training course.
also improvement in the percentage of patients who received One surprising finding was that half of the patients in
neurovascular status assessment and documentation, from 26% RTCs were motorcycle riders rather than pedestrians, contrary
(11) to 62% (28) (p = 0.0002), and for whom wound photog- to previous studies done in Malawi6,8. This could be explained by
raphy was performed before debridement, from 0% (0) to 51% the rise of the motorcycle taxi business in Malawi since 2020.
(23) (p = 0.01). However, there was no significant difference in Most of these motorcycles are not registered, and the drivers do
Gustilo-Anderson wound grading (p = 0.372), type of antibiotics not undergo certified driver’s training29. There is a need for the
(p = 0.588), temporary immobilization (p = 0.878), or median Ministry of Health, Directorate of Curative and Rehabilitation
time to antibiotics (p = 0.103). Tetanus prophylaxis remained Services, Directorate of Road Traffic and Safety Services, Malawi
low in both phases, at 2% (1) before and 4% (2) after the guideline Police Services, Kabaza Association of Malawi, and all stake-
training course (p = 1) (Table III). holders to devise strategies to sensitize the public regarding road
traffic safety issues and reinforce road traffic laws.
Place and Type of Anesthesia for Open Fracture Treatment The data indicate a significant improvement in the per-
The percentage of patients undergoing debridement in the centage of patients who underwent wound debridement in the
operating room increased from 19% (8) to 69% (31) (p = operating room under general or spinal anesthesia (p = 0.001).
0.01). Similarly, the type of anesthesia changed (p = 0.001), This is contrary to a previous study that showed that general rather
with the percentage who had debridement under general or than regional anesthesia was commonly used before and after
spinal anesthesia significantly increasing from 5% (2) to 38% implementation of the open-fracture-treatment guideline30. The
(17) and from 12% (5) to 29% (13), respectively (Fig. 1). difference may be because our study was performed at a combi-
nation of central and district hospitals. Most district hospitals have
Definitive Treatment and Referral of Severe Open Fractures only 1 main operating room to treat all conditions that require
There was no significant difference in the type of definitive surgery (obstetrics, general surgery, and orthopaedics) and 1 minor
treatment (p = 0.42); at least as many cases were treated with operating room in the emergency department for minor emer-
POP before 52% (16) and after 42% (15) the guideline training gencies19. Obstetric cases are typically prioritized in the main
course than with other methods. Most of the definitive treat- operating room, in accordance with Malawi’s Safe Motherhood
ments were performed by OCOs in both phases, 58% (25) before Initiative program19,31,32. However, studies have shown that when a
and 78% (35) after the guideline implementation. There was also patient with an open fracture is fully anesthetized, a more thorough
no significant difference in the median days to definitive treat- debridement can be achieved, which may reduce the possibility of
ment (p = 0.159) or in who performed the surgery (p = 0.065) infection33,34. A need for good teamwork and coordination between
between the groups. Additionally, the median days to referral anesthesia, obstetrics and gynecology, surgery, and orthopaedics is
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TABLE III Initial Assessment and Management of Open Fractures Before and After the Guidelines*

Before (N = 43) After (N = 45) P Value

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ATLS assessment made and documented 60% (26) 82% (37) 0.029
Neurovascular status assessed and documented 26% (11) 62% (28) 0.0002
Gustilo wound grading 0.372
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Not documented 42% (18) 26% (11)

Type I 21% (9) 31% (14)
Type II 16% (7) 13% (6)
Type IIIA 16% (7) 13% (6)
Type IIIB 5% (2) 13% (6)
Type IIIC 0% (0) 4% (2)
Radiograph 93% (40) 96% (43) 0.487
Time to antibiotics† (hr) 4.5 (1.25-42) 8 (1-24) 0.103
Types of antibiotics‡ 0.588
Ceftriaxone 63% (27) 80% (36)
Metronidazole 28% (12) 40% (18)
Penicillin 16% (7) 22% (10)
Flucloxacillin 21% (9) 13% (6)
Gentamicin 7% (3) 7% (3)
Doxycycline 7% (3) 4% (2)
Amoxicillin 0% (0) 4% (2)
Ciprofloxacin 0% (0) 4% (2)
Not documented 14% (6) 7% (3)
Tetanus toxoid vaccine 2% (1) 4% (2) 1
Temporary immobilization 0.878
POP slabs 65% (28) 71% (32)
Skin traction 2% (1) 4% (2)
None 12% (5) 11% (5)
Bandage only 0% (0) 0% (0)
External fixator 0% (0) 0% (0)
Not documented 21% (9) 13% (6)
Wound photography 0% (0) 51% (23) 0.01

*Values are given as the percentage of patients with the number in parentheses, except for time to antibiotics, which is given as the median with
the IQR in parentheses. †56% (49) of the patients had missing data. ‡59% (52) of the patients received more than a single type of antibiotic

crucial for optimizing use of operating room space within limited outcomes, but further study is required to understand the effect
resources. and feasibility of immediate referral15,41. There is also a need to
The facts that POP remained the definitive open fracture develop clear referral protocols to improve the referral system
treatment for almost half of patients both before and after for severe open fractures to central hospitals for nailing and
guideline implementation, with delays when severe injuries early soft-tissue coverage as well as for increasing orthopaedic
(Gustilo-Anderson IIIA and IIIB) were referred to central hos- and plastic surgeon capacity for district hospitals25.
pitals, can be explained by the ready availability of POP and There was no significant difference in the overall compli-
OCOs in most district hospitals and inadequate ambulance cation rate between the 2 groups (p = 0.152. The infection rate in
services to transfer patients to central hospitals35-38. This is similar our study is similar to the approximately 18% rate in studies from
to previous studies in Malawi, but studies in Nigeria and the U.K. and from other LMICs9,15. Improving surgical expertise
southwest Cameroon have shown that open fractures were ini- in soft-tissue management might help reduce infection rates,
tially treated with external fixation or intramedullary nailing and particularly in terms of wound closure and complete debride-
reconstructive surgery by orthopaedic and plastic surgeons15,39-41. ments42. Many LMICs, including Malawi, have very limited plastic
Immediate referral of severe open fractures to central hospitals surgeon availability for open fractures43. During the study, there
for orthopaedic and plastic interventions might improve patients’ were only 2 plastic surgeons working in government hospitals in
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Fig. 1
Types of anesthesia before and after the MOA/AOA open fracture guidelines.

TABLE IV Definitive Treatment and Complications Before and After the Guideline*

Before (N = 43) After (N = 45) P Value

Definitive treatment† 0.42

POP 52% (16) 42% (15)
External fixator 42% (13) 42% (15)
Internal fixation 6% (2) 3% (1)
Straight arm traction 0% (0) 3% (1)
Skeletal traction 0% (0) 8% (3)
Amputation 0% (0) 3% (1)
Days to definitive treatment and debridement 0 (0-1) 1 (0-1.5) 0.159
Debridement and definitive treatment performed by 0.065
Orthopaedic clinical officer 58% (25) 78% (35)
Orthopaedic surgeon 9% (4) 0% (0)
Trainee orthopaedic clinical technician 2% (1) 0% (0)
Surgical intern 0% (0) 4% (2)
Other 0% (0) 2% (1)
Not documented 26% (11) 9% (4)
Referral site 5% (2) 7% (3)
Complications‡ 0.152
Wound infection 21% (9) 11% (5)
Compartment syndrome 0% (0) 0% (0)
Amputation 5% (2) 7% (3)
Other 2% (1) 4% (2)
Death 0% (0) 7% (3)
Debridement before referral§ 40% (4) 64% (7) 0.083
Days to referral 1 (0-1) 1 (0-3) 1

*Values are given as the percentage of patients with the number in parentheses, except for days to definitive treatment and days to referral, which
are given as the median with the IQR in parentheses. †24% (21) were referred. ‡73% (64) of the patients did not develop any of the listed
complications. §48% (10) of 21 patients had missing data on debridement before referral.
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Malawi, neither of whom was available in the study sites21. Furthermore, long-term outcomes were not analyzed in
Additionally, 13% of the patients treated after guideline im- this study and remain unknown. Short to long-term outcomes
plementation were diagnosed with a Gustilo-Anderson type-IIIB and complications of open fractures can include infection, am-
injury, which could have equally benefited from soft-tissue putation, compartment syndrome, nonunion, malunion, and
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reconstructive surgery (Table III). These open fractures should chronic osteomyelitis. Future studies should also focus on the
be treated with early antibiotics and safe and adequate de- long-term outcomes of patients with open fractures. The addi-
bridement to reduce the risk of infection, and greater plastic tion of infographics on open fracture guidelines and temporary
surgeon availability at tertiary hospitals is needed to provide patient note recording forms as part of the implementation
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early soft-tissue coverage25. package during the training might have made the training course
The administration of tetanus toxoid vaccine (TTV) pro- more effective and at least temporarily improved the manage-
phylaxis remained at a low rate of 4%, which stands in stark contrast ment of open fractures. There is also a need for additional studies
to the findings of Mkandawire et al., who reported an increase to to evaluate retention of the gained knowledge on open fracture
95% after implementation of the open fracture guideline compared management over time.
to 60% before the guideline32. The difference in TTV prophylaxis
rates might be attributable to the recent demand for TTV, partic- Conclusions
ularly among pregnant women and women of reproductive age, as This study suggests that the training course on the MOA/AOA
part of the Expanded Programme on Immunization (EPI)44. As a guidelines in open-fracture management combined with the
result, the priority for TTV administration is primarily pregnant practice of these evidence-based guidelines can lead to at least
women, with less emphasis placed on patients with open fractures44. short-term improvement in the management of open fractures
One of the recorded deaths in our study was attributed to tetanus and significantly contributes to the improved documentation of
infection; therefore, future research initiatives and ongoing im- open fracture treatment. However, it is essential to acknowledge
plementation efforts involving government policymakers should that our study primarily focused on short-term outcomes. Addi-
emphasize the importance of TTV administration for patients with tional in-depth studies are warranted to establish a more com-
open fractures. prehensive understanding of the long-term outcomes as well as
perform a broader exploration of potentially influential factors,
Limitations such as the mechanism of injury.
Overall, the rate of missing data was 25% because part of the
study was retrospective. Furthermore, data capture was man- Appendix
ual. This contributed to the high rate of missing data for Supporting material provided by the authors is posted
important variables such as definitive treatment, wound clo- with the online version of this article as a data supplement
sure, and infection rate, which had the potential to bias the at jbjs.org (http://links.lww.com/JBJSOA/A614). n
stratification of the results according to the Gustilo-Anderson
classification. Implementing direct electronic data entry could
help minimize missing data in future studies.
We refrained from stratifying infections on the basis of the
mechanism of injury, such as crocodile bites. Crocodile bites Maureen Sabawo, BSc1
pose a considerable challenge and often result in complex open Zahra Jaffry, BSc(Hons), MBBS, MRCS, PGCert2
fracture injuries with infections stemming from a variety of oral Linda Chokotho, PhD, MPH, MBBS3
microbes associated with these incidents. We therefore did not Alexander Thomas Schade, MPH, FCS(ECSA), MBBS4,5
perform analyses according to the injury mechanism to prevent 1Kamuzu University of Health Sciences, Blantyre, Malawi
any potential impact on the interpretation of the value of early
surgical intervention for the remaining cases45. The current liter- 2Barts Health NHS Trust, The Royal London Hospital, London, England
ature on animal bites emphasizes the variability in risks, man-
3Malawi University of Science and Technology, Mikolongwe, Malawi
agement algorithms, and potential complications associated with
different types of bites, including crocodile bites46. Despite these 4Malawi-Liverpool-Wellcome
differences, there is a consensus that prompt intervention is vital Trust Clinical Research Programme,
Blantyre, Malawi
for alleviating symptoms and reducing complications46. A further
comprehensive review and synthesis of the existing literature is 5Liverpool School of Tropical Medicine, Liverpool, England
needed to shed light on the fundamentals of the treatment of open
fractures resulting from crocodile bites. Email for corresponding author: [email protected]

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